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Health in Scotland 2004

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Health in Scotland 2004

CHAPTER 3: HEALTH PROTECTION

Health Protection Scotland

In April 2004, a new Scottish health protection organisation began to take shape. The project to establish Health Protection Scotland (HPS) was managed by the Scottish Centre for Infection and Environmental Health (SCIEH), which now forms the major part of this new organisation, but other functions from National Services Scotland will also be added. SCIEH became known as Health Protection Scotland with effect from 8 November 2004.

The remit given by the Scottish Executive to Health Protection Scotland is to work, in partnership with others, to protect the Scottish public from being exposed to hazards which damage their health and to limit any impact on health when such exposures cannot be avoided.

It will seek to achieve this by:

  • ensuring a consistent, efficient and effective approach in the delivery of health protection services by NHSScotland and related agencies
  • co-ordinating the efforts of public health agencies in Scotland in health protection, especially when a rapid response is required to a major threat
  • helping increase the public understanding of and attitudes to public health hazards and facilitating their level of involvement in the measures needed to protect them
  • being the source in Scotland of expert advice and support to government, NHS, other organisations and the public on health protection issues
  • helping develop a competent health protection workforce
  • improving the knowledge-base for health protection through research and development.

The focus will be on the deployment of evidence-based advice and on co-ordination and action in response to ongoing or acute challenges to health from a communicable or environmental hazard. It will be the operational arm of the national health protection response. HPS will work with NHS Boards to ensure an effective health protection response and will advise the Scottish Executive on appropriate actions.

The functions of Health Protection Scotland are:

  • monitoring the hazards and exposures affecting the people of Scotland and the impact they have on health
  • co-ordinating national health protection activity
  • facilitating the effective response to outbreaks and incidents
  • research and development into health protection priorities
  • providing expert advice on health protection
  • lending operational support to local health protection organisations
  • monitoring the quality and effectiveness of health protection services
  • supporting the development of good professional practice in health protection
  • promoting the development of a competent and confident workforce in health protection
  • commissioning national reference laboratories services.

Within the Scottish Executive, the focus will be on policy development, policy implementation and evaluation, and liaison with the rest of the UK and with Europe. Health Protection Scotland, with other sources, will contribute to and offer advice on policy development.

Environment and Health

In line with the priorities agreed for Health Protection Scotland, surveillance activities within the Environmental Health team have focussed primarily on ensuring that the data collected are made readily available for use by practitioners. The three complementary systems, the Scottish Environmental Incident Screening System (SEISS), the Environmental Health Surveillance System for Scotland (EHS3) and the Scottish Food Surveillance System (SFSS), address a breadth of environmental agents, sources and pathways by which the population may be exposed to environmental hazards via air, land, water and food. Efforts this year have concentrated on using these systems, developed in partnership with a range of stakeholders, to inform and support operational activity. Thus the systems can be seen to support them in their statutory role in food safety, in assessing the health impact from environmental quality and in responding to public health incidents involving hazardous substances.

Development of an electronic version of SEISS has enabled instant access to the data system by contributors, allowing NHS Boards, Local Authorities and others to view incident reports and to interrogate the system via a password-protected interface. Data on environmental exposures collected via EHS3 have also been made available to the public via a collaborative initiative with Scottish Neighbourhood Statistics, ensuring wide access to information on the quality of local environments within Scotland. Development continues on SFSS on behalf of the sponsoring agency, the Food Standards Agency (FSA) Scotland, and it is now utilised by Scotland's Local Authorities, with proposals underway to introduce a complementary module to record data on animal feedstuffs.

Immunisation and Vaccine-preventable Diseases of Childhood
Changes to the childhood immunisation programme in 2004

All children in Scotland continue to be offered protection against diphtheria, tetanus, pertussis, polio, Haemophilus influenzae type b (Hib), meningococcal serogroup C (MenC), measles, mumps and rubella. In 2004, this programme was improved by the introduction of three new combination vaccines - DTaP-IPV-Hib for children at two, three and four months, dTaP-IPV or DTaP-IPV for pre-school children and dT-IPV for teenagers. These vaccines offer protection against the same diseases at the same ages as previously, but with improved safety and efficacy. Vaccine uptake rates for children at age two years are shown in Figure 3.1.

Figure 3.1: Vaccine uptake, at age 24 months, Scotland, 1995-2004 (Q3).

line chart

Disease epidemiology, including measles, mumps and rubella

The number of notifications and laboratory reports for vaccine preventable diseases in 2004 is shown in Table 3.1. Of particular note has been an increase in the number of mumps infections across Scotland in 2004. These cases have almost all been in teenagers and young adults (ages 13-25 years) and are due to their not having had the opportunity to receive two routine doses of MMR in childhood, as in now the case. Outbreaks of mumps in this vulnerable unimmunised population began to appear over the last three years in England and Northern Ireland, followed by one in Dumfries and Galloway in 2002.

Table 3.1. Vaccine-preventable diseases: notifications and laboratory reports, Scotland, 2003 and 2004.

Notifications

Laboratory reports

2004
(provisional)

2003
(provisional)

2004
(provisional)

2003

Measles

249

200

2

15

Mumps

3592

182

1810

57

Rubella

226

159

2

1

Hib

na

na

22

27

Diphtheria

0

0

0

0

Tetanus

1

1

1

0

Pertussis

95

71

58

51

Poliomyelitis

0

0

0

0

This outbreak, mainly concentrated in the West of Scotland, began in November 2003. It was recognised from the start that there was, on epidemiological grounds and international evidence, no cost-effective intervention which would completely control this situation. This was because:

  • two doses of MMR are required for effective prevention of mumps
  • vaccine uptake of up to 85% is required in this age group in order to prevent mumps circulating in the population. Previous experience showed that it would be very difficult to achieve these overall levels. For example, with the MenC campaign (when meningitis was leading to a significant number of deaths in adolescence), final uptake was only 24% in
    20 to 24 year olds in Scotland. Stopping mumps transmission by offering vaccination to this age group did not therefore appear to be a realistic option
  • evidence from the US demonstrated that even compulsory immunisation of military recruits was not cost-effective. The benefit/cost ratio was 0.2, as the cost of universal immunisation considerably outweighed the savings from avoiding admission to hospital. This is because a large proportion of this age group is already immune. The researchers concluded that a programme to immunise susceptible individuals alone would be likely to show a benefit.

What was required in Scotland were steps to contain as far as possible the mumps outbreak. Expert advice recommended a risk-reduction strategy: protection was offered to all individuals in the risk age groups who wished protection and to people in high-risk settings, such as schools, universities and colleges, where appropriate. HPS assessed the overall level of susceptibility among 13-25 year olds to be around 30%, with a peak of approximately 55% in 17 year olds.

SEHD therefore encouraged health professionals to offer MMR vaccination to all 13 to 25 year olds and, especially 17 to 20 year olds, in high-risk settings such as educational institutions. The Department of Health in England, in response to the situation, issued a reminder to all GPs to offer immunisation to teenagers and young people. SEHD took the further step of asking NHSScotland Boards to conduct individual risk assessments on specific educational institutions. This has resulted in a number of joint local initiatives between Boards and university authorities, for example in Forth Valley and Lothian.

For younger children, routine figures for uptake of MMR vaccine at age 24 months have remained at 85-90% in recent years ( Figure 3.1). The future risk of measles, mumps and rubella transmission in Scotland therefore continues to be carefully evaluated, in a project by HPS and the University of Strathclyde. Lower levels of MMR uptake mean that there could be a gradually increasing risk of measles in the future. Options to ensure as complete protection as possible, particularly by primary school, are therefore being considered.

Communicable Diseases

Gastro-intestinal infections

Figure 3.2 shows the number of laboratory reports for gastro-intestinal infections in Scotland from 1983 to 2004.

Figure 3.2. Gastro-intestinal infections: laboratory reports 1983-2004.

line chart

Campylobacter

Campylobacter is recognised as the most common bacterial cause of infectious intestinal disease in the industrialised world. In 2004, 4,365 isolates of Campylobacter had been reported to HPS, a decrease of 80 isolates (2%) on the same period in 2003. This continues the downward trend observed since the peak of Campylobacter infection in Scotland in 2000, when a total of 6,482 isolates were reported. No general outbreaks of Campylobacter infection have been reported to HPS in 2004.

Escherichia coli

Escherichia coli O157 (E. coli O157) case numbers rose by 41% in 2004, with 209 cases reported compared to 148 in 2003. Gradual reductions in numbers over time may reflect the recommendations of Scotland's E. coli O157 Task Force,(1) but the extent of the decrease in 2003 was probably unusual (Figure 3.3).

Scotland is one of few countries worldwide conducting national follow-up of E. coli O157 patients. Person-to-person spread accounted for 13% of patients, emphasising that hygiene is as important in isolated and family cases as it is in outbreaks. Thirty-nine per cent of patients required admission to hospital, with 10% admitted for two weeks or longer.

In 2004, 90 isolates of non-O157 E. coli were reported, of which 8% possessed verotoxin genes, compared with 21% of the 39 non-O157 isolates reported in 2003.

Figure 3.3: E. coli O157: Outbreak and sporadic cases Laboratory isolates Scotland 1985-2004.

line chart

Enhanced Surveillance of Haemolytic Uraemic Syndrome and other Thrombotic Microangiopathies (ENSHURE)

In Scotland, enhanced surveillance of Haemolytic Uraemic Syndrome (HUS) and other thrombotic microangiopathies (ENSHURE) began in 2003, following a recommendation by the Scottish Executive/FSA Joint Task Force on E. coli O157 (1). Up to December 2004, there were 22 reports of HUS and nine reports of thrombocytopaenic purpura (TTP).

All reports of HUS were associated with verotoxin-producing E. coli, with the O157 serotype responsible for 21 of 22 reports and a non-O157 responsible for the remaining case. All patients who developed HUS recovered initially. However, of those who developed TTP, none recovered completely, one third were dialysis-dependent and there was one fatality.

Outbreaks of infectious intestinal disease

In 2004, 207 general outbreaks of infectious intestinal disease were reported to HPS ( Figure 3.4) compared to 295 outbreaks for 2003. Five outbreaks of Salmonella were reported in 2004 including one associated with a cruise ship and one of S. Newport which was part of a larger
UK-wide outbreak. Ten outbreaks of E. coli O157, one of E. coli O86 and one of E. coli O55 have been reported, compared with eight outbreaks of E. coli O157 during the whole of 2003. Norovirus has continued to be the most frequently reported cause of outbreaks, accounting for 69% of all outbreaks in 2004. Hospitals and residential institutions are the two principal locations and account for 37% and 47% respectively of such outbreaks.

Figure 3.4: General outbreaks of Infectious Intestinal Disease reported to HPS in 2004.

pie chart

Salmonella

During 2004, 1143 cases of Salmonella were reported to HPS, a decrease of 9% on the number reported in 2003. Much of this decrease was due to a decline in reports of S. Enteritidis (607 compared to 692). As seen in 2003, Phage Type 1 remains the most frequently reported phage type of S. Enteritidis. There have been no outbreaks of non-PT4 Enteritidis associated with Spanish eggs, as seen in England and Wales.

Respiratory Infections

Influenza

2004 demonstrated the difficulty that accompanies influenza ('flu') vaccine production each year. It also providing a warning about the pandemic potential of highly pathogenic avian influenza (HPAI) emerging from human contact with affected poultry and the potential role of wild migratory fowl in country to country spread.

Flu vaccine supply

The rapid production, distribution and administration of flu vaccine following the composition being set by the WHO each spring is a feat of international co-operation. Each year this process is subject to a number of challenges before the population can be offered vaccination prior to
the arrival of the winter flu season. One such problem was the withdrawal in September 2004 of the flu vaccine Fluvirin (Chiron) from the vaccine supply chain. This affected Scotland disproportionately because more than 50% of the vaccine order was with this company (compared with 10% for England). Scotland faced a significant challenge in arranging for the rapid re-supply from other manufacturers. It was overcome by partnership working among the Department of Health, SEHD, the vaccine producers, vaccine wholesalers, Scottish community pharmacists and General Practitioners in a re-supply process co-ordinated by HPS.

Thanks to this rapid re-supply of vaccine to affected General Practices and much additional effort by healthcare workers, there has been little demonstrable adverse affect on vaccine uptake. Interim analysis suggests that Scotland will approach the 70% target for vaccine uptake among the over 65s. Lessons learned from the problems encountered are being reviewed to inform future flu vaccine procurement and distribution programmes.

Flu activity as reported from influenza-like illness (ILI) presentations to the GP Flu Spotter Scheme has remained within baseline activity and laboratory samples submitted from the Scottish Enhanced Respiratory Virus Infection Surveillance (SERVIS) scheme and from routine laboratory returns have demonstrated a good match between the flu vaccine and circulating strains of flu virus in the community.

Avian influenza

2004 saw the re-emergence of highly pathogenic avian influenza H5N1 in many countries within South-East Asia. Rapid spread was attributed to asymptomatic carriage and excretion of H5N1 by wild migratory waterfowl and their subsequent contact with poultry. Control measures introduced to deal with the problem resulted in the culling of millions of chickens and other affected poultry flocks in order to reduce the risk to humans. People becoming infected with both human flu and HPAI at the same time could result in the evolution of a novel strain retaining the pathogenicity of avian form and the communicability of the human form.

Figure 3.5: World distribution of confirmed human cases of avian flu.

map

By the end of January 2005, there had been 52 confirmed human cases of whom 39 had died in Vietnam and Thailand in two waves of infection ( Figure 3.5). Evidence suggests that isolated incidents of limited human to human transmission can be expected from avian flu in humans. The H5N1 HPAI has not yet fulfilled the requirement for a flu virus of true pandemic potential. However, SEHD and HPS keep this situation under close scrutiny and will refine the pandemic plans to take account of new information becoming available on human and avian influenzas.

Invasive pneumococcal disease

Following the success of influenza vaccination campaigns aimed at the over 64s, SEHD recommended that the same age group should be eligible to receive immunisation in winter 2003/04 against invasive pneumococcal disease (IPD). IPD is well known to account for significant morbidity and excess mortality during the winter months, particularly in older age groups. The 23-Valent pneumococcal polysaccharide vaccine (23 PSV) confers protection against over 90% of IPD infections.

Early indications on the outcome of the vaccination programme for the over 65s (on an estimated uptake of 66%) include a reduction in the overall incidence of disease in this age group of over 20% compared with the four previous winters ( Table 3.2). Additionally, taking account of recent trends over time ( Figure 3.6), reductions in expected incidence were highly significant for both 50-64 and over 65 age groups.

Work to determine the effectiveness of the pneumococcal polysaccharide vaccine in these cases of IPD is nearing completion and will allow the success of the vaccine programme to be evaluated.

Table 3.2. Invasive Pneumococcal Disease Incidence by winter season and age-band.

Age-band

Mean Incidence Rate (IR) over four previous winters

IR 2003/04

% Change

0-4

16.19

24.02

+48.4%

5-34

1.83

3.71

+103.2 %

35-49

4.46

5.43

+21.9 %

50-64

8.04

8.18

+1.8%

65+

26.90

20.62

-23.3%

Figure 3.6: Invasive Pneumococcal Disease Incidence by winter season 1999/2000 to 2003/04.

line chart

Meningococcal disease case fatality

While the year 2003 demonstrated the lowest case fatality rate (CFR) of 2.5% for the past 10 years (four deaths), 16 deaths were recorded in 2004, giving a case fatality of 12.3%. It is always difficult to comment on single year comparisons with rare diseases such as meningococcal infection and the very low number of deaths in 2003 means that the pattern of deaths will be considered over a two year rolling average. Overall CFR remains under 8% ( Figure 3.7).

Figure 3.7: Meningococcal disease case fatality rates (CFR): Group B and All cases 1994-2004.*

bar chart

Blood-Borne Viruses

Hepatitis and HIV among injecting drug users

In 2004, an estimated 1,800 people in Scotland were newly diagnosed with Hepatitis C Virus (HCV) infection. This figure is similar to those for each of the previous five years and brings the total number of diagnoses to around 20,000. With an estimated 50,000 individuals in Scotland having been infected with HCV, this means that around 30,000 remain undiagnosed. Approximately 90% of infections have been acquired by injecting drug users (IDUs) and data from a variety of sources in 2004 indicate that the incidence of HCV among this population remains high at 10-30% per year.

The Lord Advocate's welcome decision to raise the limit of the number of needles and syringes available to injectors at needle/syringe exchanges will in time reduce injectors' need to share injecting equipment and thus reduce their likelihood of acquiring HCV. A study undertaken in 2004 is evaluating the impact of this initiative. Interventions such as methadone maintenance, aimed at reducing the prevalence of injecting drug use, may be having a considerable impact, as indicated by preliminary findings from studies evaluating its effects and estimating the prevalence of injecting drug use in Scotland.

In addition to the prevention of HCV among injectors, Scotland's other principal HCV-related public health challenge is the identification and treatment of those who would benefit most from therapy. The Royal College of Physicians of Edinburgh's Consensus Conference on HCV, held in April 2004, recommended aiming HCV testing at former injectors, particularly those over 40 years of age because, if infected, they are likely to have moderate or severe but potentially treatable HCV disease. This case-finding and other prevention and awareness activities will be emphasised in a proposed Action Plan for HCV in Scotland, currently being prepared by SEHD.

HIV transmission among injectors is still uncommon and there is evidence to indicate that the spread of Hepatitis B among this group is in decline. This trend is contemporaneous with a sharp increase in the uptake of Hepatitis B vaccination among injectors as a result of the Scottish Prison Service policy to offer vaccine to all inmates.

Human Immunodeficiency Virus (HIV) and other Sexually Transmitted Infections

In 2004, 365 diagnoses of Human Immunodeficiency Virus (HIV) were reported to Health Protection Scotland. This figure compares with annual totals of 258 and 250 in 2003 and 2002, respectively, and an annual average of between 150 and 180 during the 1990s ( Figure 3.8). The 2004 total exceeds the previous highest annual number of diagnoses on record (348 in 1986) and more Men who have Sex with Men (MSM) (124) and heterosexuals (175) were diagnosed in 2004 than in any previous year.

The principal reason for the increase in diagnoses among MSM is the dramatic rise in the numbers of persons undergoing attributable HIV testing. This is particularly pronounced in the Genito-urinary Medicine (GUM) clinic setting and reflects clinicians' and health advisers' increasing tendency to recommend an HIV test to all clinic attendees (not known to be HIV infected) who present with symptoms suggestive of a new sexually transmitted infection. This approach was recommended in the consultation document, published in 2003, on Scotland's Sexual Health and Relationship Strategy.

Figure 3.8: Annual number of new HIV diagnoses, number of infected patients accessing CD4 monitoring and ART by year in Scotland 1994-2004.

bar chart

* ART (anti-retroviral therapy) defined here as dual therapy or more

Although prevalence data to December 2003 do not indicate any appreciable increase in the incidence of HIV among MSM, the rise in cases of infectious syphilis from six in 2001 to 45 in 2003 and 156 in 2004 among this population points to increasing levels of high-risk behaviour ( Figure 3.9). This increase, almost exclusively confined to attenders of GUM clinics in Glasgow and Edinburgh, has occurred despite the local NHS Boards' campaigns to increase awareness. Further efforts, including the availability of rapid (20 minute) syphilis testing facilities in Greater Glasgow, are being made to alert MSM to the risks of engaging in unprotected anal and oral sexual intercourse.

Figure 3.9: Infectious syphilis in MSM and rectal gonorrhoea* in all males: Scotland 1994-2004

line chart

*Source: Scottish Neisseria Gonorroea Reference Laboratory

As was the case last year, the increase in the number of heterosexual male and female diagnoses of HIV is mainly due to increasing numbers of persons from high HIV prevalence countries in sub-Saharan Africa (e.g. Zimbabwe) coming to Scotland, coupled with increased testing of this population. Of the 114 (this number is likely to increase as some cases are still under epidemiological investigation) Africans diagnosed in Scotland during 2004, two-thirds are female. As yet, there is little evidence to indicate that there is any appreciable onward spread of HIV from this group into Scotland's indigenous heterosexual population. For example, prevalence among heterosexuals with a UK nationality who attend GUM clinics remains steady at one in 1000. Nevertheless, other indicators of unprotected sexual intercourse among heterosexual men and women indicate that the potential for HIV transmission remains high: in 2004, for example, genital herpes simplex and genital chlamydia diagnoses increased by 3% and 11% respectively.

Despite the increase in new HIV diagnoses, HIV-related deaths remained low and stable at 40 to 50 per year during 1999/2003 (the 2004 total of 14 is low as a consequence of delayed reporting). The number of HIV-infected individuals in specialist care (as indicated by the numbers of persons having a CD4 count test to establish how well their immune system is functioning) and receiving Anti-Retroviral Therapy (ART) has increased in recent years. The number in specialist care rose by 35% from 1,302 in 2000 to 1,756 in 2004 and the number of people taking ART increased by 37% from 860 in 2000 to 1,176 in 2004 ( Figure 3.8). There is no evidence to indicate that access to care and treatment in Scotland is restricted by exposure category or country of origin. This is reassuring in the context of approximately one-third of diagnoses in recent years originating from sub-Saharan African countries. With an even greater annual increase in numbers of persons in specialist care and on therapy in 2004, Scotland's most pressing HIV challenge is to ensure that all infected persons who need treatment and care receive it.

Healthcare Associated Infection (HAI)

The prevention and control of HAI is important in terms of the safety and well-being of patients and of the resources consumed by potentially avoidable infections. HAI includes infections acquired in hospital (apparent before and after discharge), those contracted in healthcare facilities by staff and those picked up while receiving healthcare outwith hospitals.

The launch of the Ministerial Action Plan for Preventing HAI led to the establishment of the HAI Task Force in January 2003, with the remit to co-ordinate implementation of the Action Plan, to monitor progress, to monitor levels of HAI and to report on progress to the Minister. Over the past two years, the Task Force has issued guidance including the Code of Practice for the Management of HAI and Hygiene, the National Cleaning Services Specification, a framework for mandatory induction training for all NHS staff, guidance for those involved in dealing with the media during incidents and national standards for infection control. A risk management guide on how to assess, prioritise and focus on the HAI risk is currently out for consultation.

The Chief Nursing Officer has accepted the position of vice-chair of the HAI Task Force and his commitment to his nurse leadership role will increase patient safety and staff workplace safety, by promoting action to reduce the levels of HAI and increase cleanliness in healthcare premises.

Public involvement and effective communications are at the heart of the working philosophy for the HAI Task Force. Earlier this year, the role that the public can play in combating HAI was set out by publishing advice for visitors to hospitals:

Five top tips on the role of the public in preventing HAIs:
  • Think about keeping patients safe before you visit. If you or someone at home has a cold or are feeling unwell - especially if it's diarrhoea - stay away until you're better.
  • Think about what you take in to patients. Food treats are best saved until they get home. Don't sit on the bed and keep the number of visitors to a minimum at any one time.
  • The most important thing you can do is to wash and dry your hands before visiting the ward, particularly after going to the toilet. If there is alcohol hand gel provided at the ward door or at the bedside, use it.
  • Never touch dressings, drips or other equipment around the bed.
  • Don't be afraid to raise concerns with members of staff in your hospital. People can sometimes forget simple things like cleaning their hands before touching a patient.
    No NHS worker should take offence at a gentle and polite reminder.

Staff training is one of the basics of tackling HAI. Educated staff contribute to a safe healthcare environment for service users, staff and visitors. The expansion of the Cleanliness Champions training programme across a range of staff groups and the general interest shown from the
non-NHS healthcare sector as well as the NHS across the UK are all welcome developments.

The second review of compliance with national standards for control of HAI was undertaken in 2004 by NHS QIS, who reported on progress in meeting standards and in delivering improvements that had been identified. They found that although HAI is considered a high priority in all Board areas, further work is needed in specific areas. This report will provide an incentive to NHS Boards to attain and maintain high standards when dealing with HAI, including effective reporting and accountability systems, infection control programmes and close monitoring.

The Task Force met almost all the recommendations set out in the National Audit Office Report into HAI Control in England published in July 2004, but is aware that there is no room for complacency.

A Primary Care Strategy Group has been established to advise the Glennie Group on how to progress the decontamination agenda in primary care. Following the publication of a detailed review of decontamination in primary care dental practice, a letter (CMO(2004)21) was issued on 25 November 2004 to all those involved in local decontamination of medical devices in the community. This letter detailed 10 priorities that all practices should address urgently.

Further details of a phased approach to compliance with the Glennie Technical Requirements (NHSScotland: Sterile Services Provision Review Group: 1st Report - The Glennie Framework, HDL(2001)66) were addressed in HDL(2005)1. Guidance on requirements for Local Decontamination Units has been published as a consultation draft and a web-based software program to assist primary care practices with the development of a decontamination procedure manual is in preparation.

Surveillance of Healthcare Associated Infections

National surveillance of HAI is co-ordinated by Health Protection Scotland. Its Healthcare Associated Infection and Infection Control Section contributes support to the Ministerial HAI Taskforce. The Section's first priority is the facilitation of infection control strategies, activities and measures at local level and its four teams work together to provide a comprehensive approach to infection prevention, control and management, and health protection.

The Scottish Surveillance of HAI Programme (SSHAIP) is developing further surveillance systems which support the HAI Action Plan and is monitoring progress in implementation. Since April 2001, quarterly reports on rates of methicillin resistant Staphylococcus aureus (MRSA) blood infections in Scotland have allowed Operating Divisions to examine their own trends in relation to Scottish rates and to take appropriate local steps to contain the spread of MRSA. Quarterly rates have been broadly stable over 2003 ( Figure 3.10), in contrast to the continuing increase in incidence of MRSA seen in many other countries.

Figure 3.10: Scottish quarterly rates of MRSA bacteraemia rates per 1,000 occupied bed days 2003/04.

line chart

Surveillance of surgical site infections (SSI) has been implemented in all acute Operating Divisions in Scotland and a second SSI report was published in November 2004. Although numbers are still too small for detailed analysis, this early information shows infection rates which are broadly consistent with English and US data ( Table 3.3) (4,5).

Table 3.3: A comparison of SSI in-patient rates by procedure with US, England and Scotland data.

Surgical procedure

US (2002)

ENGLAND
(1999)^

SCOTLAND
(2003)

Breast surgery

1.9%

*

1.9%

Abdominal hysterectomy

1.4%

2.5%

1.5%

Caesarean Section

2.8%

*

2.2%

Operations for fractured neck of femur

1.8%

3.4%

2.1%

Hip replacements

0.9%

2.9%

1.7%

Knee replacements

0.8%

2.1%

0.9%

^ The English programme used an adapted version of the US definition of infection, thus comparisons of rates of infection should be given careful consideration.
* Procedure not included in the English surveillance programme.

The infection rates resulting from collection of these preliminary data indicate that the rates of in-patient infection in these programmes in Scotland are broadly similar to those published by NNIS in the USA. As the programme of surveillance continues in Scotland and larger denomination data are attained, these types of comparative data will become more meaningful.

Other HAI surveillance projects include:

  • a National Scottish Prevalence survey of HAI, the pilot due to start in spring 2005
  • catheter-associated urinary tract infections
  • HAIs in intensive care units
  • HAI outbreaks.

This wide-ranging, multi-disciplinary approach is laying firm foundations for the prevention and control of HAI in Scotland. The goal is cultural change, nothing less, but that will not happen without an acceptance that infection control is everyone's responsibility.

variant Creutzfeldt-Jakob Disease (vCJD)

In 2004 the CJD Incidents Panel recommended specific public health precautions for some recipients of UK sourced plasma products, who may have been exposed to potential vCJD infectivity. These precautions aimed to minimise the risk of any possible onward transmission of vCJD.

HPS co-ordinated a notification exercise in Scotland, together with the Health Protection Agency (HPA) England and patient and professional representatives. Input from the Scottish National Blood Transfusion Service was central to this exercise. Patients considered to be 'at-risk' of vCJD for public health purposes are being contacted by their doctors and informed of the precautions they will need to take, including those in healthcare settings.

In addition to the standard infection control measures used in all healthcare settings, specific precautions are needed when persons considered 'at-risk' for vCJD undergo medical care involving surgical procedures.

Following the plasma products exercise, HPS responded to requests for advice on the additional measures required for the newly identified 'at-risk' patients. Enquiries generally related to the vCJD transmission risk for specific procedures, many relating to flexible endoscopes, both in respect of past and proposed surgical interventions. Advice given commonly related to the indications for single-use instrumentation, the requirements for decontamination of re-usable instruments and the quarantining of instruments where necessary.

Travel Medicine

Health Protection Scotland provides travellers and their advisers with detailed information on health risks. This is continually updated and is used both by the public ( www.fitfortravel.nhs.uk) and health professionals (www.travax.nhs.uk). The information allows an assessment of the potential health risks for different countries and how to prevent these. It also links to many other useful sites including the Foreign and Commonwealth Office which advises on safety issues. HPS works closely with the National Advisory Travel Health Network and Centre for England and Wales, the Joint Committee on Vaccination and Immunisation (JCVI) and the Advisory Committee for Malaria Prevention (ACMP).

Travel Medicine surveillance work focuses upon early recognition of outbreaks of infection which may have implications for travellers or which raise the possibility of transmission of serious infections in Scotland after travellers return home. It therefore relates closely to the work of colleagues in Public Health. Collaboration with the Scottish National Resource Centre for Ethnic Minority Health helps to provide guidelines on clinical management for those caring for patients, including refugees, who may have contracted health problems overseas.